Pre-authorization request form
The Pre-authorization request form includes the details of the pre-authorization request provided by a payer for a patient.
| Field | Description |
|---|---|
| Primary pre-auth number | Primary pre-authorization number generated by the payer organization. |
| Secondary pre-auth number | Secondary pre-authorization number generated by the payer organization. |
| Primary diagnosis | Main condition in a patient submitted by the practitioner as the reason for the healthcare service requested in the pre-authorization request. |
| Medication prescription | Medication prescription for which the pre-authorization request is created for the patient. |
| Status | Approval status of the pre-authorization request. |
| Date approved | Date when the pre-authorization request was approved by the payer organization. |
| Valid from | Start date of the pre-authorization request validity period. |
| Valid until | End date of the pre-authorization request validity period. |
| Notes | Instructions or explanation for the pre-authorization request. |
Parent Topic:Healthcare and Life Sciences Service Management Core reference